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THE CLINICAL PROGRAMS IN THE DIVISION OF GASTROENTEROLOGY ...

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The Clinical Programs in the Division of Gastroenterology, Hepatology and Nutrition (2000-2001) - 1 - THE CLINICAL PROGRAMS IN THE DIVISION OF GASTROENTEROLOGY, HEPATOLOGY AND NUTRITION1. Introduction: One of the major strengths of the Division of Gastroenterology, Hepatology and Nutrition at the Virginia Commonwealth University Health System-Medical College of Virginia is the level of clinical expertise across all of the major areas of these subspecialties.2. Specific programs: The specific clinical programs are discussed below:A: Endoscopy:Faculty: Dr. Alvin Zfass Dr. Donald Kirby Dr. Donald Switz Dr. Arun Sanyal Dr. Michael Pandak Dr. Mitchell Schubert Dr. Doug Heuman Dr. Anastasios Mihas Dr. Doumit BouHaidar Dr. Bimaljit SandhuFacilities: The endoscopy suite at MCV and at the McGuire VA Medical center are both state-of-the- art facilities. Both suites have fluoroscopy available in the suite allowing endoscopic procedures requiring fluoroscopy to be performed in the endoscopy suite. The endoscopy suite at MCV currently has 5 procedure rooms. This suite will move to the Gateway building where it will have seven procedure rooms. All endoscopic data are maintained in an electronic database which is networked with the “Cori centers”. The Con centers are supported by a grant from the National Institutes of Health.Description:Routine procedures: Approximately 6000 routine endoscopic procedures are performedannually at MCV while about 3000 procedures are performed at the VAMC. These include theentire gamut of endoscopic procedures including use of hemostatic devices.Pancreato-biliary procedures: Approximately 300-350 ERCPs are performed between MCVand the VAMC. These include both routine as well as highly complicated biliary procedures. Themajority of these procedures are therapeutic procedures. New “mother-baby” scopes and “ERCP-EUS” are being incorporated among the procedures performed.Endoscopic ultrasound: A cutting-edge EUS program exists and approximately 250 EUSprocedures are performed annually. EUS has been performed only at MCV but will now beavailable at the VAMC after July 2001. EUS-guided biopsies are routinely performed and EUSstudies of portal hypertension are being started. EUS probes are also available for routine use asrequired.Photodynamic therapy: A major treatment program for Barrett’s esophagus with PDT exists.PDT of cholangiocarcinomas are being planned.

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The Clinical Programs in the Division of Gastroenterology, Hepatology and Nutrition (2000-2001) - 2 -Endoscopic suturing: Endoscopic suturing is available for creation of a fundoplication. Pilottrials for endoscopic gastroplasty are planned in the near future.Trans-nasal endoscopy: Ultrathin scopes for ambulatory, non-sedated, trans-nasal endoscopicexamination will be available by July 2001.Endoscopic resections: Endoscopic mucosal resections are performed and it is anticipated thatendoscopic colonic resection and re-anastamosis will be tested in the next 1-2 years.B: Swallowing Disorders:Faculty: Dr. Alvin Zfass Dr. Jay KuemmerleFacilities: Patients with these disorders are seen in Dr. Zfass and Dr. Kuemmerle’s clinics. Currently, a relatively small number of patients are seen. It is planned to expand this in to a dedicated multi-disciplinary clinic involving speech therapy, ENT, neurology and gastroenterology depending on the volume of patients that are seen.Description: Patients with all types of swallowing disorders and transfer dysphagia will be seen. Evaluation of upper esophageal sphincter dysfunction as a cause of pulmonary disease will also be a major focus of this clinic.C: Esophageal disorders:Faculty: Dr. Alvin Zfass Dr. Jay Kuemmerle Dr. Michael PandakFacilities: A clinic dedicated to esophageal disorders is being opened in the ambulatory care center of MCV. In addition to Cl faculty, it is anticipated that Dr. DeMaria and Dr. Broderick from surgery will also see selected patients. This clinic will be run every other week unless patient volume requires it to be run more frequently.Description: Patients with all types of esophageal disorders will be seen here. These will include difficult reflux cases, non-cardiac chest pain, esophageal motility disorders, achalasia, Barretts esophagus etc. A multi-disciplinary approach will be taken to provide state-of-the- art care for patients with these disorders.D: Functional Bowel Disease and Motility Disorders Clinic:Faculty: Dr. Jay Kuemmerle Dr. Donald Switz Dr. Donald Kirby Dr. Alvin Zfass Dr. John LongFacilities: Patients are currently being seen in the individual physicians clinics. It is anticipated that a specific dedicated clinic for these patients will be opened by the end of 2001.Description: A multi-disciplinary approach will be taken to manage these patients including

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The Clinical Programs in the Division of Gastroenterology, Hepatology and Nutrition (2000-2001) - 3 - use of pharmacologic and behavioral therapy. Translational research based on the ongoing basic motility research at MCV will be used to further improve the care of afflicted patients. Dr. Foxx-Orenstein and Kuemmerle will play an important role in developing the clinical research programs in this area.E: Pelvic floor disorders:Faculty:Facilities: Ambulatory care center at MCV and at Stony point clinicDescription: Dr. Foxx-Orenstein has a special interest and experience in the evaluation and management of patients with a variety of pelvic floor disorders including chronic constipation as well as fecal incontinence. It is anticipated that eventually a multi- disciplinary clinic with an urologist, gynecologist, neurologist and psychologist will be opened.F: Womens Health:Faculty:Facilities: Inpatient services, Ambulatory care center at MCV and at Stony point clinicDescription: Dr. Foxx-Orenstein is particularly interested in gastrointestinal disorders as they relate to womens health. She has taken a leadership role at a national level with respect to such disorders and is an authority on the subject. She has a particular interest in the management of post-partum gastro-intestinal disorders.G: Inflammatory Bowel Disease:Faculty: Dr. Don Kirby Dr. Alvin Zfass Dr. Don Switz Dr. Michael Pandak Dr. Souheil Abou-Assi Dr. John KuemmerleFacilities: Inpatient services, Ambulatory care center at MCV, VA Medical CenterDescription: A multi-disciplinary clinic dedicated to the management of inflammatory bowel disease is being opened in the ambulatory care center at MCV. Patients at the VAMC are seen in the GI clinics at the VAMC. The treating team will include gastroenterologists, surgeons, and nutritionists. This clinic will be dedicated to providing state-of-the-art care for patients with inflammatory bowel diseases. These physicians will develop translational research protocols with Dr. Martin Graham, a recognized and funded investigator in inflammatory bowel disease.H: Gastro-intestinal cancer prevention:Faculty: Dr. Alvin Zfass Dr. Doumit BouHaidar

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The Clinical Programs in the Division of Gastroenterology, Hepatology and Nutrition (2000-2001) - 4 - Dr. Souheil Abou-AssiFacilities: Ambulatory care center at the Medical College of VirginiaDescription: Patients with pre-cancerouS lesions in the Cl tract e.g. adenomatous polyps will be seen here with the specific intention of providing the best treatments for the prevention of cancer. Also, family screening for specific disorders e.g. hereditary pancreatitis will be available.I: Gastro-intestiflal oncology clinic:Faculty:Facilities: Inpatient services, Massey Cancer CenterDescription: A multi-disciplinary clinic, including surgical oncologists, gastroenterologiStS, pathologists, radiation therapiest and medical oncologists, dedicated to the management of gastro-intestiflal cancers after they develop.J: Feeding and nutrition access:Faculty: Dr. Donald KirbyFacilities: Inpatient services, Ambulatory care center at the Medical College of VirginiaDescription: This clinic is dedicated to the management of patients on long-term TPNas well as those who require enteral feeding access on a long-term basis.K: Obesity clinic:Faculty: Dr. Donald KirbyFacilities: Ambulatory care center at VCU-MCVDescription: This clinic is dedicated to the management of obesity. Diet, exercise, behavior modification, pharmacologic and endoscopic treatment are all available at this clinic. The physicians in this clinic work in close concert with Dr. Harvey Sugerman, Dr. John kellum and Dr. Eric DeMaria who perform a large number of proximal gastric bypass operations for weight loss.L: Pancreatitis clinic:Faculty:Description: This is a multi-disciplinary clinic dedicated to the management of chronic pancreatitis. Also translational research utilizing data from basic scientific studies at the VCU-MCV to improve the care of such patients as well as to better understand this condition is performed in this clinic. In addition to the Cl faculty, this clinic is also supported by Drs DeMaria and Broderick fromsurgery and by a team of nutritionists and pain management experts.M: Pediatric Gastroenterology:

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The Clinical Programs in the Division of Gastroenterology, Hepatology and Nutrition (2000-2001) - 5 -Faculty:Facilities: Inpatient services, Nelson clinic, Medical College of Virginia HospitalsDescription: All varieties of gastro-intestinal and hepatic disorders in children are seen and managed. Patients with advanced liver disease are evaluated for liver transplant at the VCU-MCV.N: Hepatology programs:Faculty: Dr. Mitchell Shiffman Dr. Arun Sanyal Dr. Velimir Luketic Dr. Richard Sterling Dr. Todd StravitzFacilities: a: MCV: Inpatient services, ambulatory care center, Stony Point clinic, telemedicine, clinical research center,transplant clinics including DePaul Hospital transplant outreach clinic. b: VA: Inpatient and outpatient services, telemedicine and transplant clinicsDescription: This is a multi-faceted program which integrates clinical care with clinical research with the goal of providing the best available treatment for individual patients and also to advance the science and art of hepatology. Over 10,000 patient contacts occur annually. The specific programs that are ongoing include:1. Viral hepatitis:Dr. Shiffman is an internationally acclaimed expert on viral hepatitis. Both routinely availabletretaments as well as a wide variety of experimental therapies are available for the managementof patients with both hepatitis B and C. Dr. Sterling is focused primarily on patients with HIV-HCVcoinfection.2. Portal Hypertension:Dr. Sanyal has a vast experience and expertise in all aspects of portal hypertension. All of themodalities for the management of portal hypertension are available. A large number of clinicalprotocols to further improve the care of patients with ascites and or varices are available both atthe VA as well as MCV.3. Cholestatic liver diseases:Dr. Luketic is primarily interested in cholestatic disorders and is nationally known for his expertisein this area. A number of clinical protocols for the management of primary biliary cirrhosis andprimary sclerosing cholangitis are available.4. Hepatic encephalopathy:Drs. Sanyal, Shiffman and Stravitz all have a clinical interest in hepatic encephalopathy. Inaddition to routine therapy, the Hemocleanse system for the management of both acute as wellas chronic encephalopathy is available. Also, new protocols for the evaluation and managementof subclinical encephalopathy are being developed.5. Nonalcoholic fatty liver disease:

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The Clinical Programs in the Division of Gastroenterology, Hepatology and Nutrition (2000-2001) - 6 -Dr. Sanyal has both a clinical and research interest in this area. A special clinic dedicated to thecare of patients with NAFLD has been opened and translational studies based on research doneat BCU-MCV in this area are being performed to develop effective therapy for this condition.6. Hepatocellular carcinoma:Protocols are in place for the management of hepatocellular carcinoma. Lesions that areamenable to local shrinking therapy with radiofrequency ablation, chemo-embolization or alcoholinjection are initially shrunk. In those who remain without visible tumor, liver transplant isperformed unless a contraindication for transplant exists. In others, various modalities are used toprovide the greatest duration and best quality of life.7. Liver transplant:Approximately 60-70 liver transplants are performed annually at VCU-MCV. A multi-disciplinaryapproach is taken for the pre- and post-transplant management of patients. Combined roundswith the surgical team is made on the inpatient services.The VA liver transplant program, directed by Dr. Heuman, is one of four such programs in theentire VA system. Patients with cirrhosis are referred from as far away as New England andPuerto Rico. An innovative telemedicine project for following VA transplant patients is supportedby a federal grant.8. Isolated Hepatocyte transplant:This was pioneered at VCU-MCV. Dr. Robert Fisher (Surgery) is in charge of this program and issupported by faculty from transplant surgery and hepatology.9. Adult live donor right-lobe liver transplant:This procedure was also pioneered at VCU-MCV. An active adult live donor transplant program isavailable. Over 50 such procedures have been performed without major donor morbidity or anydonor mortality.